How Much Time Do I Have to Complete My Chiropractic Documentation?
That is a frequent question we hear, when we are teaching at state and national chiropractic conventions. Literally, your chiropractic documentation should be completed contemporaneously, meaning at the time you are rendering the service(s) you are providing.
There is an expectation that you can complete your documentation process within 24 hours. And Medicare has stated in the Medicare Claims Processing Manual (Chapter 12 – Physicians/Nonphysician Practitioners, Section 30.6.1.) that you have 24-48 hours to complete your note-taking process. However, tread cautiously here, because you are given up to 48 hours for the following reasons:
“Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.”
These specific situations should not normally hold up the completion of a typical chiropractic SOAP note, and certainly should not happen more than 1-4% of the time with all your chiropractic documentation.
Use of a Clinical Scribe Can Help Chiropractors
One solution to this chiropractic documentation concern can be the use of a clinical scribe. Each doctor must weigh the pros and cons to determine if having another person enter their data is right for their workflow in their office. If a clinical scribe is going to be used in your chiropractic practice, there are two requirements:
- The CMS guidelines for the use of a clinical scribe must be upheld.
- A policy detailing how the practice uses a clinical scribe must be entered into the compliance manual(s).
Weigh the pros and cons of using a clinical scribe in your practice as you complete the KMC University Library lesson on timely chiropractic documentation.